MATERIAL TRANSFER REQUEST FORM
UCSF OFFICE OF INNOVATION, TECHNOLOGY & ALLIANCES
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SECTION 1 – CONTACT INFORMATION
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UCSF Principal Investigator
Name:
Phone:
Email:
Department:
Campus Location:
Additional Campus (for dual-appointees):
UCSF Co-Researcher
Name:
Phone:
Email:
UCSF Lab Assistant or Administrator
Name:
Phone:
Email:
Outside Organization Scientific Contact
Organization Name:
Organization Status: For-profit Non-profit
Name of Scientist:
Phone:
Email:
Outside Organization Legal or Administrative Contact
Name:
Title:
Phone:
Email:
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SECTION 2 – Material to be Transferred
Do you wish to send or receive the Materials from the Outside Organization?
Receive (Incoming)Send (Outgoing)
Enter the EXACT name of the MATERIAL:
Type of MATERIAL (check all that apply):
Human Specimen Human Data: De-identified Human Data: Limited Data Set
Human Data: Personal Health Information (PHI)
Plasmid Compound/chemical Biologicals (antibodies, cell lines) Animal
Other:
Is there an alternate source of the MATERIAL?
Yes No
Has the MATERIAL been described in a publication?
Yes No
Is the MATERIAL a vertebrate animal or will the MATERIAL be used in a live vertebrate animal?
Yes No
If YES, attach a PDF of the Institutional Animal Care and Use Committee (IACUC) Approval Letter with your email submission.
Is the MATERIAL human embryonic stem cells?
Yes No
If YES, is the MATERIAL listed on the NIH Human Embryonic Stem Cell Registry?
Yes, the Registry number is: No
Do you requireCommittee on Human Research (CHR) approval letter(s)?
Yes No
Do you have the appropriate Committee on Human Research (CHR) approval letter(s)?
Yes No
If YES, please attach the letter(s) with your email submission.
If NO, please explain why:
Will the MATERIAL be used in humans, or for clinical diagnostic purposes, or as part of a clinical trial?
Yes No
If YES, immediately contact the Office of Innovation, Technology & Alliancesat or 415.502.1603. You may disregard this form.
Is the MATERIAL infectious or biohazardous?
Yes No
If YES, do you already have approval from the appropriate Biosafety Committee?
Yes No
SECTION 3 – Research Proposal
Please provide a description of the RESEARCH that requires the MATERIAL and attach additional information as necessary with your email submission:
Does the RESEARCH involve a joint research plan and/or collaboration with a scientist at another organization?
Yes No
If YES, is the joint research plan and/or collaboration with the Outside Organization?
Yes No
Will the MATERIAL be commingled with materials received from 3rd parties?
Yes No
If YES, list the 3rd party materials and who provided them:
Will you or the Outside Organization make derivatives or modifications of the MATERIAL?
Yes No Not sure
Is the RESEARCH or the MATERIAL relevant to an invention disclosed or about to be disclosed to theOffice of Innovation, Technology & Alliances?
Yes No
SECTION 4 – Funding
Do you or your spouse, domestic partner or dependent children have a financial interest in the Outside Organization?
Yes No
If YES, the Principal Investigator must complete the California Form 700U.
The original signed copy of the Form 700-U must be submitted via campus mail to:
Campus Box 1016
Attn: MTA
Please indicate the current or anticipated funding source(s) for the RESEARCH that require(s) the MATERIAL to be sent to or received from the Outside Organization (check all that apply):
Federal Grant
Non-Profit Grant
Industry Sponsored Research Agreement
Department Funds
HHMI Funds
Other Source of Funds
SECTION 5 – REIMBURSEMENT
Do you want the Outside Organization to reimburse you for the samples?
Yes No
If YES, please provide the approximate number of samples and fee ($) per sample:
Number of samples:
$/sample:
SECTION 6 – Additional Information
When submitting this questionnaire to , please attach any email correspondence or information related to your request that you think will help to expedite the process of executing your MTA.
BEFORE SUBMITTING– Review your answers to make sure that they are accurate & complete.
SUBMIT yourcompleted MTA Questionnaire to
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